Injured Worker Information
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Injured Worker Information Form. This is a California form and can be use in General Workers Comp.
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Tags: Injured Worker Information, IMC-12203A, California Workers Comp, General
Arnold Schwarzenegger, Governor
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
Industrial Medical Council
DWC - Medical Unit
P.O. Box 420603
San Francisco, CA 94142
INJURED WORKER INFORMATION
Panel #:
Date of Request:
Date of Issue:
Claim No.:
Claims Administrator:
Date of Injury:
To:
SELECTED QUALIFIED MEDICAL EVALUATOR PANEL:
PHYSICIAN'S NAME
ADDRESS
Tel. No.:
SPECIALTY
YEARS IN PRACTICE
PHYSICIAN'S EDUCATION
PHYSICIAN'S TRAINING
PHYSICIAN'S NAME
ADDRESS
Tel. No.:
SPECIALTY
YEARS IN PRACTICE
PHYSICIAN'S EDUCATION
PHYSICIAN'S TRAINING
PHYSICIAN'S NAME
ADDRESS
Tel. No.:
SPECIALTY
YEARS IN PRACTICE
PHYSICIAN'S EDUCATION
PHYSICIAN'S TRAINING
IMC FORM 12203A (rev. 2/96)
Authority cited: Sections 139.2, 4061, 4062, Labor Code.
Reference: Section 139.2, Labor Code.
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